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Minnesota Well and Boring ��O O� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H � <br /> �o���Y Name WELL AND BORING SEALING RECORD M���esota���q�e No. <br /> ��1 Minnesota Statutes.Chapter 103/ or W-series No. <br /> iLeave biank if no�knowni <br /> Township Name• ��Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approxima[e Date Well <br /> viVi3ti 1 1 ( �3 17 4����1��J�14 � "",-,�yr � or Boring ConsVucted <br /> t..�`., <br /> Numencal Street Address or Fire Number and City ot Well or Boring Location � � <br /> :�s29 �tal gay R�,-�d (�c��o, �� Depih Before Sealing �� ft Onginal Depth �` Fl <br /> Show exact location of well or bonng Sketch map of well 02 bQnng Stahc Water Level ccurate <br /> in section grid with��X��. location.showing prope li�. <br /> roads,and b I�gs. ❑Approximate <br /> N <br /> _� � � _ _�_ �'� / <br /> r -�' -r � �,� <br /> i`���� �ingle Aquiter ❑Multiaquifer `���tt. below above land surface <br /> i � i i � \'\ <br /> _I_ _J_ _1_ _I_ � CASING TYPE <br /> W 1 I I . I E \� <br /> I I I I �� ~ <br /> -r -�- -r- -r - <br /> i � i i „� i""' � Steel ❑Plastic ❑Tile ❑Other <br /> _ _ b�e � <br /> I I I I <br /> I I I I � ,�� � <br /> S _j � Screen from to � fi. Open Hole hom �o ft. <br /> �—1 mile—� �;`J OBSTRUCTION/DEBRIS/FIIL <br /> PROPERTY OWNEfl'S NAME . �Obstruction ❑Debris ❑Fill <br /> Jirni�e Holtz <br /> Type ot debris/obsiruction ��'�� <br /> Mailing Address d different than property address mdicated above. <br /> Obstrudion/Debris/Fill removed9 ❑Yes ❑No <br /> BGX�V PUM P <br /> NdVG'iLZ@� �[i. �?r3�� <br /> � � -�� ❑Removed ot Present ❑ Other <br /> � <br /> CASING <br /> GEOlffGICAL MATERIAL COLOfl HAHDNESS OF FROM TO <br /> FORMATION <br /> Diameter � � Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate eslimated formation log from nearby well or boring. <br /> '�'/ <br /> i <br /> �in.from �L to �..� ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.from �o ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CAS�NGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing PeAoration/Removal <br /> in.from to fL ❑Pertorated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type o(perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material A.,JE;^� f��'�'7'r��✓� from � to �L fl. yards �bags <br /> from to tt. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informa6on contained in ihis report is <br /> true to the best o(my knowledge. <br /> Gt.?I3 S'I�C�f.�T,l� WF�,L, D�2II.I,ING O0., Il�TC. 271!"i <br /> Contractor Business Name License or Registration No. <br /> '�� � L3""G(T74 <br /> __j;,��rf �, — �.�'' i;:; <br /> �h ¢ Representative Signature Dafe <br /> Jim Ant� <br /> ���A��G�� H 55009 <br /> Name ol Person Sealing Well or Boring <br /> H601434-01 <br />